Health inspection·March 4, 2024

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview with the DON on February 29, 2024, at 11:35 AM, in the presence of the Nursing Home Administrator, the DON stated Resident 8's UTI should have been indicated on the MDS and it is the expectation of the facility for MDS assessments to be accurate. 28 Pa. Code 211.12(d)(3)(5) Nursing services Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 2 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on facility policy review, clinical record review, and staff interviews, it was determined that the facility failed to review and revise the resident plan of care for two of 28 residents reviewed (Residents 118 and 128). Findings include: Review of facility policy, titled Interdisciplinary plan of care- development. Review, and update, last revised October 13, 2017, revealed It is the policy of this facility to develop an individualized plan of care for each resident, and review and update the care plan as needed .Care plans will be updated with the quarterly OBRA (Omnibus Budget Reconciliation Act) schedule, as significant changes occur and by the interdisciplinary team as changes arise. Review of Resident 118's clinical record revealed diagnoses that included post-traumatic stress disorder (PTSD - a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event) and generalized anxiety disorder (condition that causes you to feel anxious about a wide range of situations and issues). Review of Resident 118's care plan on February 27, 2024, at 11:17 AM, revealed a care plan focus created March 17, 2023, for I have post-traumatic stress disorder (PTSD) due to, with an intervention of, I need staff to be aware of my triggers to trauma. My triggers include. During a staff interview February 28, 2024, at 10:24 AM, with the Director of Nursing (DON) and Nursing Home Administrator (NHA), the surveyor requested additional information regarding Resident 118's PTSD diagnosis indicators and triggers not being identified on the care plan. During an additional staff interview February 29, 2024, at 12:15 PM, with the NHA, she indicated the facility was unable to determine Resident 118's PTSD triggers due to Resident 118's inability to communicate his triggers and not having any relatives familiar with his diagnosis. The NHA stated that Resident 118's care plan had been updated now, and it was the facility's expectation that the care plan would have been updated timely. Review of Resident 128's clinical record revealed diagnoses that included congestive heart failure (CHF excessive body/lung fluid caused by a weakened heart muscle), emphysema (a lung disease which results in shortness of breath due to destruction and dilatation of the alveoli), and acute pulmonary edema (a condition where fluid accumulates in lung tissues causing shortness of breath, wheezing, and coughing up blood). Review of Resident 128's physician orders on February 26, 2024, revealed an order for, Diet (Regular) Diet Consistency (regular) Liquid Consistency (Thin) 1200 ml (milliliter- unit of measure) fluid restriction, with a start date of January 9, 2024. Review of Resident 128's clinical record revealed a fax from Resident 128's cardiology appointment on January 29, 2024, with the following recommendations: 2300 mg (milligram- unit of measure) sodium restriction, 1800 ml fluid restriction. Review of Resident 128's clinical record revealed an evaluation note on January 30, 2024, that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 3 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm stated, Fluid restriction updated to 1800, weight changed to three times weekly and fax to HF (heart failure) clinic on Fridays. Review of Resident 128's care plan on February 28, 2024, at 10:00 AM, failed to reveal that Resident 128 is to follow an 1800 ml fluid restriction and sodium restricted diet. Residents Affected - Few During an interview with the DON on February 28, 2024, at 1:22 PM, the surveyor requested information on whether Resident 128's fluid restriction should be 1200 ml or 1800 ml, and whether she was on a sodium restricted diet or not. Email correspondence with the DON on February 29, 2024, at 10:40 AM, revealed that Resident 128 should have had the 1800 ml fluid restriction starting January 30, 2024, and she explained the facility process of following a low sodium diet. During an interview with the DON on February 29, 2024, at 11:29 AM, she revealed Resident 128's care plan should have been updated to reflect the 1800 ml fluid restriction and sodium restriction. 28 Pa. Code 211.12(d)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 4 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm Based on clinical record review, observations, and staff interviews, it was determined that the facility failed to precisely and effectively monitor hydration status and implement a therapeutic diet for one of 28 residents reviewed (Residents 128). Residents Affected - Few Findings include: Review of Resident 128's clinical record revealed diagnoses that included congestive heart failure (CHF excessive body/lung fluid caused by a weakened heart muscle), emphysema (a lung disease which results in shortness of breath due to destruction and dilatation of the alveoli), and acute pulmonary edema (a condition where fluid accumulates in lung tissues, causing shortness of breath, wheezing, and coughing up blood). Review of Resident 128's physician orders on February 26, 2024, revealed an order for, Diet (Regular) Diet Consistency (regular) Liquid Consistency (Thin) 1200 ml (milliliter- unit of measure) fluid restriction, with a start date of January 9, 2024. Review of Resident 128's clinical record revealed a fax from Resident 128's heart failure clinic appointment on January 29, 2024, with the following recommendations: 2300 mg (milligram- unit of measure) sodium restriction, 1800 ml fluid restriction. Review of Resident 128's clinical record revealed an evaluation note on January 30, 2024, that stated, Fluid restriction updated to 1800, weight changed to three times weekly and fax to HF (heart failure) clinic on Fridays. Observation of Resident 128 in her room, eating her lunch, on February 27, 2024, at 12:36 PM, revealed she had a 240 ml can of soda on her lunch tray and mug of water on her tray table. Observation of Resident 128 in her room, eating her breakfast, on February 28, 2024, at 9:12 AM, revealed she had a 240 ml cup of coffee on her lunch tray and mug of water on her tray table. Observation of Resident 128 in her room, eating her lunch, on February 28, 2024, at 12:31 PM, revealed she had a 240 ml can of soda on her lunch tray, a 360 ml Styrofoam cup of water, and mug of water on her tray table. Review of copies of Resident 128's meal tickets from lunch on February 27, 2024; breakfast on February 28, 2024; and lunch on February 28, 2024, revealed she was on a 1200 ml fluid restriction, and should only have been provided 180 ml of fluids per meal from dietary. The meal tickets failed to reveal indication that Resident 128 was on a sodium restricted diet. During an interview with the Director of Nursing (DON) on February 28, 2024, at 1:22 PM, the surveyor requested information on how Resident 128's fluid restriction was monitored, whether it should have been 1200 ml or 1800 ml, and whether she was on a sodium restricted diet or not. Email correspondence with the DON on February 29, 2024, at 10:40 AM, revealed they do not break down fluid restrictions by shift, and that nurse aides and licensed practical nurses document how many milliliters of fluid the resident consumes throughout the day. The DON also revealed that Resident 128 should have been following an 1800 ml fluid restriction, starting January 30, 2024, and she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 5 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 explained the facility process for following a sodium restricted diet. Level of Harm - Minimal harm or potential for actual harm During a follow-up interview with the DON on February 29, 2024, at 11:29 AM, the surveyor revealed the concern with Resident 128's diet order not being updated to reflect the cardiology recommendations from January 29, 2024, observations of extra fluids provided by dietary at meals, and inadequate monitoring and implementation of the fluid restriction. The surveyor inquired how the nursing staff would know how many fluids to provide the resident each shift, and the DON replied, they wouldn't. She further revealed that Resident 128's diet order and meal tickets should have been updated to reflect the 1800 ml fluid restriction and sodium restriction. Residents Affected - Few 28 Pa. Code 211.12(d)(1)(3)(5)Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 6 of 7 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395058 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/04/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Rest Haven-York 1050 South George Street York, PA 17403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on review of facility policy, observations, record review, and resident and staff interviews, it was determined that the facility failed to provide respiratory care consistent with professional standards of practice for one of 28 residents reviewed (Resident 65). Residents Affected - Few Findings include: Review of facility policy, titled Aerosol Therapy- Ordering, Administering, Documenting, last revised August 14, 2014, revealed, It is the policy of this facility to order, administer, and document aerosol therapy per physician's order .Clean mask/mouthpiece after each use with soap and water and wrap in a dry paper towel. Place on bedside table with nebulizer machine. Review of Resident 65's clinical record revealed diagnoses that included chronic kidney disease (CKD - a condition characterized by a gradual loss of kidney function), type 2 diabetes mellitus (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and osteoporosis (a condition that weakens bones and increases the risk of fractures). Observation of Resident 65 on February 26, 2024, at 10:51 AM, revealed she was up in her chair and her nebulizer mask was lying out on her bedside table. During an interview with Resident 65 on February 26, 2024, at 10:52 AM, she revealed That is for my breathing treatments. I have a cold. Observation of Resident 65 on February 26, 2024, at 12:14 PM, revealed she was up in her chair and her nebulizer mask was lying out on her bedside table. Review of Resident 65's clinical record revealed a physician order for ipratropium-albuterol solution for nebulization; 0.5 mg-3 mg(2.5 mg base)/3 mL (units of measure); Amount to Administer: 1 vial; inhalation Every 4 Hours PRN (as needed) .After each use mask is to be cleaned with soap and water, wrapped in a paper towel, and stored in a colander. Review of Resident 65's MAR (Medication Administration Record - documentation for treatments/medication administered or monitored), revealed Employee 6 (General Practice Nurse) administered the ipratropium-albuterol solution via nebulizer mask to Resident 65 on February 26, 2024, at 7:51 AM. During an interview with the Director of Nursing on February 29, 2024, at 11:26 AM, she confirmed she would expect Resident 65's nebulizer mask to be stored per physician's order and facility policy. 28 Pa code 211.12(c)(d)(1)(2)(5) Nursing Services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395058 If continuation sheet Page 7 of 7